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GUJHS. 2004 April; Vol. 1, No. 3
PROPOSITION: SHOULD THE UNITED STATES ADOPT A NATIONAL HEALTH CARE PLAN AND PROVIDE UNIVERSAL HEALTH CARE COVERAGE?
Stephanie Deutsch, NHS ’04
Pro: A single-payer system, in which the government finances health care but the delivery of health care services is under private control, is the only way to achieve distributional efficiency in the United States’ health care system. The United States tops all other countries in per capita expenditures on health care, yet the country still has nearly 45 million citizens uninsured, many with only limited coverage, skyrocketing health care costs, long-term care issues, and relatively negative health indicators. The United States should adopt a single-payer system because it would reduce the cost of care and eliminate wasteful, costly bureaucracy and provide all citizens with preventive and primary care, improving the quality of care for all. Medicine must be a public service and not a business.
Con: Americans have a traditional reliance on individual responsibility and a commitment to the ideal of a limited national government, in accord with the principles of market justice. Under market justice, health care is viewed as an economic good, health care services are based on individual purchasing power, rationing is based on ability to pay, and there is individual responsibility for health. Americans should not adopt a national health care plan because embedded in the nation’s culture are the deontological values of individual responsibility, self-reliance, and capitalism, and the market-oriented society supports private rather than government solutions to social problems of health. Like all other economic goods, health care is a business.
Background: Fighting For Universal Coverage – 1880s to Today
From the late 1800s to the present day the delivery of health care in the United States has been an issue of debate, and the campaign for some form of universal government-funded health care has stretched for nearly a century (Physicians for a National Health Program). Between the 1880s and 1912, the government had little active role in health care delivery, but during the Progressive Era of the early 20th century, reformers worked to improve social conditions for the working class. The American Association of Labor Legislation led the campaign for a government- funded national health insurance program by drafting a model bill in 1915, and the American Medical Association actually supported this bill. However, the powerful American Federation of Labor repeatedly denounced the compulsory health insurance plan as a paternalistic plan that would weaken and usurp the unions’ role in determining social benefits; many workers then opposed government-funded insurance in an effort to maintain union strength (Physicians for a National Health Program). Opposition grew among doctors, labor unions, and insurance companies that contributed to the failure of these early efforts, but all the while health care delivery was undergoing a major transformation as health care costs, especially hospital costs, began to steadily increase. Health care became a profitable business rationed by ability to pay and system began to take on a market-justice character. President Franklin D. Roosevelt, during his 1933-45 term, attempted to include provisions for national health insurance in his Social Security legislation, but the provision was dropped for fear the bill would not pass Congress. Again in 1939 FDR attempted to include his national health insurance plan in the Wagner National Health Act of 1939, his support motivated in part by his experiences in the World War and the Great Depression. However a conservative resurgence in Congress fought against government funding and squashed the plan. Support for national health insurance was crushed during Truman’s presidency, during the Communist attacks and early years of the cold war; government-controlled health insurance became entangled in the Cold War and opposition to this “socialist medicine” became a growing Congressional crusade. Furthermore, the AMA argued that a national health insurance plan would make doctors “slaves” (Physicians for a National Health Program). The closest steps toward a government-funded health plan were taken in 1965 by President Johnson, when he signed into law the Great Society legislation that put into action Medicare and Medicaid.
For years the fight for universal national health care coverage has failed, largely because of interest group influence, ideological differences, cultural values like rugged individualism and self-reliance, the entrepreneurial character of American medicine, the rise of powerhouse companies like Blue Cross and other private insurance plans, the association of public programs with charity and poverty, and fragmentation of public policy (Physicians for a National Health Program). Health care has risen to be a commercial giant driven by financial incentives, and professionals have made a lot of profit in the system. However, the pluralistic, market-justice based character of the health care delivery system has resulted in disparities in quality of health care services and disparities in who receives these services. As the system continues to become entrenched in bureaucratic waste and rising costs, and as millions continue to be denied the care they need, the question arises as to whether or not legislation should be passed to institutionalize a government-funded, universal health care program in the United States.
Pro: The United States Should Adopt Universal Health Care
What’s Wrong With The Health System? Pluralism, the Uninsured, and Managed Care
Nearly 40 million Americans in the United States do not have health insurance, and this is because the United States is the only industrialized country that does not have a national health insurance program for its citizens (Himmelstein, 1989). Millions of other Americans fail to get adequate insurance benefits through their employers and struggle to meet the premiums every month for private plans. Furthermore, over 100,000 people fail to meet these costs and lose their health insurance each month, so this makes for a very tenuous situation as health care costs continue to rise.
The number of Americans without any access to the health care system at all is staggering (National Coalition for the Homeless). The U.S. Census Bureau in September 2000 published a report that nearly 16% of the entire U.S. population lacks access to the health care system because they are uninsured, and the report also states that despite Medicaid nearly 1/3 of all poor Americans – including working families, the elderly, and children – do not get all of the health care services they need annually (National Coalition for the Homeless). For these impoverished individuals, health problems often precipitate homelessness, because for people struggling to meet the costs of daily living, the onset of an illness is often a burden too expensive to bear. Poor health and lack of access to care are among the causes of homelessness (National Coalition for the Homeless). Untreated health conditions, especially those infectious and communicable diseases like tuberculosis or HIV, become costly public health issues when people cannot afford treatment for these maladies, and the lack of universal health care coverage endangers public health (National Coalition for the Homeless).
Because uninsured Americans lack access to preventive care and early prevention services, they often go without care until easily treatable conditions become medical emergencies, using the emergency room as their primary care. This costs the hospitals exorbitant amounts of money and requires extensive billing and wasteful paperwork to get paid for these services, and often the costs trickle down to every other American paying for health care (Himmelstein, 1991). The increased costs of serving the uninsured are absorbed by providers as free care, passed on to the insured via cost-shifting and higher health insurance premiums, or paid by taxpayers (American College of Physicians). The absence of a universal health care system then costs American citizens more money. Thus, medical treatment for the uninsured is often more expensive than preventive, acute, or chronic care of the insured because the uninsured are more likely to wait until their conditions are emergencies (American College of Physicians). Making preventive medicine accessible to the uninsured would increase overall access to health care and may substantially reduce the burdens of cost and illness faced by the United States (American College of Physicians).
The pluralistic health care delivery system is characterized by corporate oligopolies; a few giant firms own and control a majority of the medical delivery systems in the nation. For example, a single firm – Columbia Health Care Association – now owns one quarter of all Florida hospitals and has announced plans to start buying in Massachusetts, and in the past year alone the firm has purchased over a dozen hospitals in Denver and Chicago, shutting the doors on unprofitable physicians and patients. Similarly, in Minnesota, three or four hospital chains dominate the market, and thus in many rural areas a single firm owns all of the health care offices, leaving patients with no choice but to use their services (Physicians for a National Health Program, Himmelstein, 1991). Managed care companies are buying up hospitals and physicians’ practices, and many managed care companies won’t form partnerships with doctors who don’t earn enough to be profitable for the company; this for-profit mentality shuts out doctors who serve patients that don’t fit in with corporate criteria (Physicians for a National Health Program).
Thus, even for those individuals who have obtained health insurance, privately or through their job, the cost-cutting principles held by managers of health insurance companies do not ensure that these individuals will get all of the care they possibly deserve. Many insurance companies make decisions about health care that should only be made by doctors or loved ones (Physicians for a National Health Program), especially when managed care plans offer financial incentives to doctors to pit them against the very patients they were trained to serve. Furthermore, nearly 25 cents of every health care dollar out a managed care plan budget is being spent on paperwork, advertising, or CEO salaries instead of on actual health care services that patients have paid for (Physicians for a National Health Program). HMO’s have managed to pit physicians against their patients by offering financial incentives for cost-cutting measures and penalties for every referral, specialized diagnostic test or hospital visit that will cost the company money. Thus patients often do not receive quality care because health care delivery has become a “business”, with doctors forfeiting the best interest of the patients and managed care companies amassing the profits. Often doctors will receive the same profit for treating a patient in their office one time or six times, so there is no incentive for the doctors to ensure the highest quality of care. Insurers are gutting benefits, denying needed care, cutting physician payment rates, and insisting on the cheapest – and most likely, not the best – form of care (Physicians for a National Health Program). Even large pharmaceutical companies are launching plans to get a cut of the profitable patient care market; Merck, Lilly and others are developing “Disease Management” subsidiaries to sub-contract with HMOs to care for patients with expensive chronic diseases, thus cutting the middleman out altogether (Physicians for a National Health Program). Clearly large, for-profit companies selling products in the field would not be unbiased parties serving the best interests of the patients.
In all other industrialized countries, a patient can go to the physician or hospital of their choice to receive care, and all standard medical services are automatically covered by a national health plan; patients never receive any medical bills or insurance bills, and all family members are covered. The government is the “single payer” for this health care plan. The patient does not have to worry about extended coverage for children, spouse, or loved one, and loss of a job never means loss of health care coverage. Preventive care is covered for healthy patients, and treatment plans are offered for ill patients, and profit is far from the primary concern. Countries like Canada, Denmark, Norway, and Sweden have these single-payer national health insurance programs; health insurance is publicly administered and most health care professionals are in private practice, so the delivery of care is privatized (National Health Systems of the World). Canada, with a population of approximately 31 million people (roughly the size of California), has a health system characterized by single-payer national health insurance, and the federal government requires that insurance cover “all medically necessary services” (McDermott, 1994). Canada spends 9.5% of its gross domestic product towards health care, and its 1998 per-capita expense was $2312 U.S. dollars (OECD Health Data 2000). The Canadian national health insurance program (“Medicare”) is a public program overseen by the federal government, funded by general tax revenues and administered by the provinces; federal contributions are tied to provincial economic conditions, so the provinces also contribute a portion of their tax revenue to the government fund (National Health Systems of the World). In addition, most Canadians also buy supplemental insurance from large group plans (like a private insurance company) that covers the expenses not provided under Medicare, such as dental care, prescription drugs, rehabilitation, and private care nursing. For the average Canadian citizen, 72% of their health care costs are covered by the national government, and the other 28% are covered by private insurance (OECD Health Data 2000). Physicians in Canada receive fees-for-service subject to pre-determined rates set by the government, and provincial medical associations represent the physicians to negotiate these fee schedules. Hospitals are non-profit organizations and operate under regional budgets with fee-for-service payment schedules, also established by the government (National Health Systems of the World). The single-payer system in Canada is better for patients and better for doctors, since the country spends near $1000 less on health care than the United States and still has greater distributional efficiency, delivering more care and greater choice of care for its citizens (OECD Health Data 2000). Denmark, a European country which recently adopted single-payer national health insurance plan, allots approximately 8.3% of its gross domestic product for health care and the 1998 per-capita expense was $2133 U.S. dollars (OECD Health Data 2000). (Just for comparison, the U.S. spends approximately 16% of its GDP on health care bureaucracy and we do not even have a nationalized system! (Physicians for a National Health Program)) The Danish system is funded by income taxes, and hospitals are run by 14 counties and the district of Copenhagen. Physicians who work in these hospitals receive set salaries pre-determined by the government and negotiated by doctors’ unions. There are no co-pays for general practitioner care, and the GP’s can then refer the patients to specialists (who work fee-for-service, covered under the government plan). However, citizens must pay for approximately 25-50% of all drug costs, so private insurance is held by about 27% of the population to cover medications and dental expenses (National Health Systems of the World).
Combining the efficiency of a single-payer system with the large amount of funding the U.S. currently has for health care would result in a better system than ever before known (Physicians for a National Health Program). It is a fact that Canadian patients have unrestricted choice of doctors and hospitals, and Canadian doctors have a wider choice of practice options than U.S. physicians (U.S. Healthcare 1994 Annual Report, OECD Health Data 2000); it is also fact that Canadians get more doctors visits, procedures, longer hospital stays, and even more transplant operations than Americans! Surveys show that Canadian doctors are happier with their health care delivery system than U.S. doctors are, and according to a 1992 OECD poll, 85% of Canadian physicians prefer their system to ours. 83% of Canadian physicians rate quality of care in Canada to be “very good” or “excellent”, and most say they would encourage others to enter the profession (OECD Health Data 2000, U.S. Healthcare Annual Report 1994). Although some Canadian physicians emigrate to the U.S., most show a clear preference for their system over the U.S. system; Canadian physician salaries have even kept up with inflation over the past 25 years, despite fee-for-service schedules! (American College of Physicians, Oliphant, 2002). OECD surveys also show extremely high patient satisfaction in Canada, and 96% of Canadian patients prefer their system to ours, while 89% rate their care as “very good” or “excellent”. Interestingly, polls show that Canadians (physicians and patients) distrust their government more than U.S. citizens do, but in terms of fiscal management, the Canadians support their publicly funded health system (OECD Health Data 2000). Satisfaction with Canadian health care services is due completely to their single-payer universal coverage system.
What exactly is “Single-Payer”?
Single-payer describes a financing system in which one entity acts as the administrator; in the case of health care, a single payer system would mean the government, or a government-run organization, would collect all health care fees and pay out all health care costs (McDermott, 1994, Himmelstein, 1989, Physicians for a National Health Program). Currently there are thousands of different health care “payers” in the health care system – HMO’s, managed care companies, private insurance companies, billing agencies, etc, and this large “multi-payer” system generates an enormous amount of wastes (just imagine the complex billing process in a doctor’s office – each HMO requires a different form to be filled out for each patient, and some plans work on post-visit reimbursement, whereas others pay physicians pre-determined fees-for-service) (Physicians for a National Health Program, Himmelstein, 1991). Under a single-payer system all hospitals, doctors, and health care providers would bill one entity, the federal government or its designees, for their services, and this would not only reduce bureaucratic/administrative waste, it would ensure that each and every American was provided the care and insurance they deserved (Physicians for a National Health Program, Himmelstein, 1991).
What does a single-payer system mean for America?
Every person deserves good health, even if they can’t afford the high cost of health care services; health care should be a human right, especially here in the United States, one of the richest nations in the world. According to a study conducted in 1991 by the General Accounting Office, national health insurance (a single-payer plan) would save the United States more than 10% of all health care costs annually by reducing paperwork, and this saved money alone would adequately cover the uninsured and provide better long-term care, home care, and medication coverage for the entire population (McDermott, 1994). Under a single-payer system all Americans would receive comprehensive medical benefits, and like Canada and Denmark, coverage would include all medically necessary services. However, proposals for a single-payer system in the U.S. extend coverage to rehabilitative, long-term and home-care services, mental health care, prescription drugs, medical supplies, and preventive public health measures (Physicians for a National Health Program). Thus care would be based on need and not on ability to pay. Legislation in Congress based on the Canadian approach had 120 sponsors in 1994, more than any other health care proposal, and although similar bills have failed, single-payer resolution seems to have support (Physicians for a National Health Program).
One proposal suggested that national health insurance would cost American families an average of only 2% of annual income (for the typical middle-income household, this translates into $731 dollars a year), and employers would pay 7% of their payroll to the government, and amount less than the percentage they already pay to cover their employees (McDermott, 1994, “Canadian Health Care: Lessons for the U.S. 1991”). Hospital billing would be virtually eliminated and instead individual hospitals would receive a lump sum from the federal government each year to cover operating expenses, the “global budget”. Hospitals would no longer close because of unpaid bills! Doctors would either be paid fee-for-service (like in Canada), or hold salaried positions in hospitals (like in Denmark). Doctors’ income would remain steady, but the disparity in salary between expensive specialists and GP’s would decrease. Delivery would remain privatized (a patient could still see their own doctor, they would just be covered under a national plan), and the government would serve only as the administrator, not the employer. The government would not control which physician the patient could or could not see, a method commonly employed by managed care companies today. The program would be federally funded and financed, and all premiums, co-payments, and deductibles – the everyday lingo of today’s managed care delivery system – would all be eliminated. With employers paying 7% of income, and employees paying 2%, 90 to 95% of all American citizens would pay less for health care (Physicians for a National Health Program, McDermott, 1994, “Canadian Health Care: Lessons for the U.S. 1991”); this would have saved the nation $225 billion dollars per year on health care costs by 2004 (Physicians for a National Health Program, McDermott, 1994, “Canadian Health Care: Lessons for the U.S. 1991”).
What would happen if the United States Adopted a Single-Payer System?
Each person, regardless of ability of pay, would receive high-quality, comprehensive medical care and unrestricted choice of doctors and hospitals, and most people would pay less overall for health care than they are paying now (Physicians for a National Health Program). Public administration of health care would ensure the fair, efficient, and equitable distribution of a human right to every individual regardless of cost. Single-payer system would just be simpler and more efficient.
Thus, a single-payer system, in which the government finances health care but the delivery of health care services is under private control, is the only way to achieve distributional efficiency in the United States’ health care system. The United States tops all other countries in per capita expenditures on health care, yet the country still has nearly 45 million citizens uninsured, many with only limited coverage, skyrocketing health care costs, long-term care issues, and relatively negative health indicators. The United States should adopt a single-payer system because it would reduce the cost of care and eliminate wasteful, costly bureaucracy and provide all citizens with preventive and primary care, improving the quality of care for all. Medicine must be a public service and not a business.
American Cultural Belief System Influences Health Care Economics
The following is a distillate of arguments promulgated against development of a single payer health care system. Health care is an economic good, and the delivery of health care is a business. The production, distribution, and consumption of health care are all based on free-market principles, and because health care is not an infinite resource, distribution will never be infinite. Societies must allocate resources according to the guiding principles of their society, ingrained in its’ value and belief system (Shi and Singh, 2001).
The value and belief system of the United States governs the training and general orientation of the health care providers, type of health care delivery settings, financing and allocation of resources, and access to health care (Shi and Singh, 2001). For these reasons, the health care delivery system of the United States has taken on a market-justice orientation; like any other economic good, medicine and health care delivery is a business. Health care delivery is subject to economic principles and market forces because it is an economic good to be purchased. It is generally understood that in the free-market, only those with purchasing power will receive the good that is offered – a social justice-based allocation of health care poses conceptual and practical difficulties in a society founded on capitalism and individualism. Americans have also been long-standing champions of capitalism, and due to this belief in capitalism, health care is viewed not as a public resource but as a good to be purchased. Americans buy health care because it is an investment that rectifies a health problem and restores health, and the investment may have a monetary pay-off when it reduces the number of sick days taken, or it may have a utility pay-off when it increases satisfaction of the patient and makes life more fulfilling (Shi and Singh, 2001). The culture of capitalism promotes entrepreneurism and self-determination, so individual capabilities have largely determined the ability to obtain health services, where, and in what quantity. Americans are consumers of health care goods and services, and any market is subject to competitive forces. The health care market works best with minimum interferences from the government. The market rather than the government can allocate health resources in the most efficient and equitable manner (Shi and Singh, 2001).
When health care is distributed according to market justice principles, as in the United States, health care is an economic good, free market conditions are assumed for health services delivery, production and distribution of services are determined by market-based demand and according to people’s ability to pay, and access to care is viewed as an economic reward for personal effort and achievement (Shi and Singh, 2001). This is compounded by American ideals of personal freedom, self-reliance, and rugged individualism. The implications of this market-based system include an individual responsibility for health, benefits distributed based on individual purchasing power, private solutions to social problems, and limited obligation to the collective good (Shi and Singh, 2001). Because the health care system of the United States is governed by market forces, and because individualistic values are so deeply embedded in American culture, access to medical care is commonly viewed as an economic reward of personal effort and achievement. Those who have the economic success should reap the reward of their diligence.
There has been a lot of debate recently regarding institutionalization of a universal health care plan in the United States that would designate the government as single-payer. There are a number of reasons why this would be a grave mistake on the part of the politicians who would vote it into action. First, Americans who have worked hard for their money and succeeded in today’s competitive society should be able to purchase whatever goods and services they desire, because this is an economic reward of their personal effort and achievement. This very principle of capitalism is what the entire nation is founded upon. If someone wants to pay a little more to get their MRI right away, why shouldn’t they be able to? (Physicians for a National Health Program). They’ve worked hard to be able to do just that. The wealthy should be able to bypass queues if they can afford an extra fee, because their success in society has afforded them this; health care is a social privilege (Shi and Singh, 2001, Physicians for a National Health Program). The medical model in the United States is founded on innovations in science and technology, like the latest high-tech body scanners, made possible because of the vast amounts of money allocated to research and development of sophisticated medical technology; furthermore, the desirability of health care delivery institutions, like hospitals and doctors, is often evaluated according to their acquisition of advanced technology (Shi and Singh, 2001). Those people with the most money should be able to use this money to get access to cutting edge technology and to see the best physicians in the business. Doctors have a financial incentive to become specialists in their field because they will be able to make the most money by serving those in need of their services, and if the sick are wealthy enough to afford the experts, they should purchase the highest quality care they can. Furthermore, physicians should see only private paying patients if they want to, because to see Medicaid patients and the poor often is not profitable for them. If a doctor sees a patient covered under Medicaid, it may take them many months to get reimbursed for this service, and physicians already lose money because of cost-shifting mechanisms that enable Medicaid patients to be seen at all. If a single-payer system was adopted, doctors would be making no profits whatsoever and would have no vested interest at all to provide patients with the amount and quality of care they deserve; why bother to serve one patient more when they are all worth the same price tag?
Another reason why adoption of a single-payer system is undesirable is because government is often repressive and inefficient. Most Americans distrust the government because of their belief that the government should stay out of “America’s bedrooms”; most individuals do not want the government interfering with private matters, especially those influencing their very health and quality of life. If the government controlled health care, it could cap how much would be spent on each individual, and those patients with serious diseases might not have access to that specialist because the government would not pay for it, or the specialist would not have incentive to practice anymore because they weren’t making a profit from the government. “Big government” should not be given the steering wheel for health care, because judging from the cost effectiveness of the defense department, the compassion of the IRS, and the efficiency of the post office, American lives would be lost in a large car crash (Physicians for a National Health Program). Big government is subject to the influences of lobbyists and interest groups, and the government might be swayed, for example, by an enticing campaign contribution from a large drug manufacturer; the government might decide to restrict Americans to drugs manufactured only by that company, leaving the sick without access to “wonder drugs”. Health care needs to be run by large for-profit corporations because it is an economic good subject to free-market forces. In addition, allowing big government to be the single controller of health care is socialist and against everything America stood for, and there are already enough socialist services in the country – retirement income support (Social Security), police and fire department, the military, etc. (Physicians for a National Health Program). Socialism is diametrically opposed to individual freedom, self-reliance, and independence, and to have the government controlling the health of the nation would be the ultimate betrayal to governmental paternalism (“The Dangers of Socialized Medicine”). The United States is already exercising its’ socialist paternalism; on December 3, 2002, the Department of Health and Human Services announced it would provide states with financial assistance for high-risk pools, non-profit organizations created by states that offer insurance to individuals who have difficulty obtaining affordable coverage because of pre-existing medical conditions (Winnick, 2002). Isn’t the government interfering enough? The country already is a welfare state (“The Dangers of Socialized Medicine”), and now the health of the nation could be controlled also? Most economists already say that the health care system is subject to an imperfect market because social justice egalitarian tenets, like Medicare and Medicaid funding, already pervade health care delivery, (Shi and Singh, 2001), so wouldn’t going with a single-payer plan just be “turning socialist”?
Single-payer may be a great idea for other countries, but in the United States it is not politically viable and is never going to happen, especially in light of what is happening with other government-run services – the Medicare trust fund is going broke (Physicians for a National Health Program). If the government cannot even efficiently handle Medicare, a policy that has been in action since 1965, how could it possibly manage all of the health care, financing, and delivery system budgeting for a billion Americans? Large states like New York and California want to have separate health care budgets for each region, with separate budgets and fee schedules for each and every physician and hospital in the region negotiated by doctors’ unions (Physicians for a National Health Program). Mere creation of the system would result in more bureaucracy, red tape, and administrative waste and paperwork than exist currently in the system! The country would not possibly save money until each and every budget detail of each and every physician in all 50 states was worked out, and this would not only lead to chaos, it would create more waste and paperwork, waste money and worsen quality. Recent political promotion of universal health care coverage advocates a single-payer solution, but what they really mean is “one source for receipts and expenditures in place of today’s multitude of insurance operations. It is national insurance, not nationalized medicine, and it can leave every bit as much choice on coverage and care as exists currently. To oversimplify, single-payer is analogous to having Medicare for everybody, with the same individual freedom to buy more if you can afford it” (Little, 2002).
Who would pay for the single-payer system? Undoubtedly a progressive financing system would be put in place that would force the rich to bear more of the burden of cost and receive less care, footing the bill for the poor. In a free-market system, one gets health care if there is money in the bank to pay for it. Plans that have called for employers to hand over 7% of their total payroll and for employees to give 2% of their annual income to the feds are probably optimistic numbers at this point, the true percentages being much higher when all of the costs are worked out. Other finance schemes have called for a $2 tax levy on cigarettes to benefit the health care budget, but “Big Tobacco” and other interest group lobbies will probably prevent that burden from being placed on their product (Physicians for a National Health Program). Therefore, who will pay the very large bill of caring for America?
The single-payer system is not working in Canada, with a population the size of California, so why would it work in the U.S.? (Physicians for a National Health Program). Recent headlines have emphasized that Canadians are fed up with their long waits for urgent types of care – it often takes over six weeks for a patient to get an appointment with a physician! (Physicians for a National Health Program, Little, 2002). However, to date there has been no documentation of increasing patient morbidity or mortality because of the length of waiting periods for procedures. Furthermore, the Canadian government has cut their health care budget significantly, resulting in less money being allotted for healthcare, and sparks are flying as Canadian physicians are being handed even lower fees-for-service (Little, 2002). Hospitals are complaining that exceeding their budget triggers an automatic audit of their administration and CEO, yet no contingency funds are allotted for emergency health needs, often compromising patient care (Physicians for a National Health Program). There is a major push for privatization of health care in Canada – many doctors want to open private practices because they just aren’t making any money off the public system, and wealthy Canadians want to pay a lower share of their incomes and get more services (Little, 2002); the progressive financing of the system, in which the rich pay more and get less care, is causing many politicians to advocate for privatization as a cost control mechanism. Last year the Canadian government spent over $100 billion dollars on health care, while private citizens spent nearly $30 billion in prescription drugs, dentists and eye care, all services not covered under the government plan; if Canadians are spending so much out of pocket, isn’t the single-payer system failing them anyway (Little, 2002)? Why would the United States want to adopt a failing system? Medicare has been covering less and less of total health care spending in Canada, and public pressure has been exerted on the government to cover more drugs, home care, and allot more money for hospitals. Health care costs are already gobbling up more of an increasing share of provincial budgets than ever before, and many politicians admit the system is failing (Little, 2002).
Americans have a traditional reliance on individual responsibility and a commitment to the ideal of a limited national government, in accord with the principles of market justice. Under market justice, health care is viewed as an economic good, health care services are based on individual purchasing power, rationing is based on ability to pay, and there is individual responsibility for health. Americans should not adopt a national health care plan because embedded in the nation’s culture are the deontological values of individual responsibility, self-reliance, and capitalism, and the market-justice dominant society supports private rather than government solutions to social problems of health. Like all other economic goods, health care is a business. A single-payer system will only offer “increasingly less benefits and frighteningly higher costs” for society (Oliphant, 2002).
Synthesis: Issue Summary and Support of Viewpoint
Health care delivery in the United States has long been the subject of debate. The nation, built upon the ideals of individualism, self-reliance, determinism, and capitalism, has struggled through the years to equate free-market economics with societal social justice duties, like caring for its’ poor and sheltering the homeless. In the face of a pluralistic, fragmented health care system characterized by large corporate oligopolies and for-profit HMO’s, the natural alternative would be to have the government fund a massive public program ensuring a basic standard of care for all individuals that would eliminate economic and class barriers to care and offer comprehensive coverage regardless of age, race, or status. The solution is not so simple, since Americans have a long-standing distrust of government, value private and personal freedoms, and strongly oppose socialist sentiment, which has for nearly a century prevented “big government” from adopting this paternalistic role over health care delivery. When it seems like the only alternative is impossible to execute, the fate of health care delivery becomes dismal.
In 1988, a Harvard professor of European literature predicted that the Berlin Wall would never fall, and certainly not in his lifetime; fortunately, he is still alive (Physicians for a National Health Program). Large social changes can occur very rapidly and transform the face of any stubborn system overnight. There is no feasible solution to the health care crisis of which I am aware. The health care delivery system is a giant albatross that is not easily struck down, a boat that has hit an iceberg and is sinking fast. Adoption of a nationalized health plan is probably the only way to prevent corporate take-over of the health care system, since individual investors that pour their money into HMO’s and managed care only perpetuate the profit-driven mindset of the delivery system itself. In other words, a corporate system will inevitably hold corporate ideals. A national public plan is not socialized medicine, but rather a form of socialized insurance, ensuring that each and every individual in the United States is guaranteed some level of care. That would be more than exists right now – today nearly 45 million people have nothing, and often illness starts the snowball of poverty and homelessness rolling. A plan offering comprehensive care would protect the uninsured, protect public health by controlling infectious and communicable diseases spread by those without access to care, and help ease the financial burden of those on the border of homelessness; it would also eliminate disparities in quality of care experienced by the wealthy versus the needy. A government-funded plan would eliminate some paperwork for doctor’s offices and drive out the financial incentives that HMO’s and managed care offers to doctors to limit costs of care, often compromising quality. Patients would no longer have price tags because an egalitarian approach would be adopted, eliminating the driving forces of the free-market that ration care by ability to pay. A single-payer system is probably not the only answer. Americans still probably will need supplemental insurance, and many individuals will need to change their attitudes about distributional efficiency and health care being a social privilege. These changes will be major ideological shifts in the nation’s culture, and may have manifestations that transcend the health care delivery system. These shifts that topple down every major cultural icon probably will be difficult, slow-moving, or may never occur at all. In this case, there needs to be an alternative plan that will ensure that those who need it most will have access to care.
There needs to be major policy changes in the health care system of this country. First, a change that can very feasibly be made is to overhaul existing programs; Medicare and Medicaid programs should expand their eligibility requirements to ensure that more individuals who are near but are not at or below the poverty line are still able to access medical care if they need it. More money, raised either by a tax levy or a mandatory percentage taken from income taxes, needs to be allotted by the federal government for these programs. A lofty, less feasible goal would be to have the government contract-out with a major pharmaceutical company, like Pfizer or Merck, to either get vouchers for those that can’t afford prescription drugs, to include prescription drug deductibles under the federal programs, or to even mass-distribute drugs at free clinics and hospitals. Some definite change needs to be made surrounding prescription drugs because their high cost often leaves the elderly or impoverished sick without access to them, or causes a financial strain that affects economic well-being. Another lofty change that needs to be made somehow is policy control of HMO’s and managed care; there needs to be either an audit of health care professionals to prevent financial incentives from motivating them to provide minimal, substandard care or some other method of cost-control that prevents patients from being just a number on a page instead of an actual person. HMO’s and managed care have become such an integral, influential part of the health care system that their elimination may never be possible.
There are significant problems with each of the sides summarized in this argument. First, adoption of a single-payer system will be difficult since significant political support favors a corporate system and American cultural values prevent easy swallowing of the socialist medicine pill. Expectations about how the program will be funded – like a 2% withdrawal from income, and a cigarette tax – may not represent the actual figures for how much the system will cost, and some Americans might not end up saving money. If delivery is private, competition will still exist and health care quality disparities may still exist since physicians would not have financial incentives to ensure adequate care. On the flip side, a single-payer system would eventually eliminate bureaucratic waste and paperwork and ensure that the millions of homeless and uninsured have access to the treatments they need and deserve, the egalitarian duty of society. While corporate HMOs and managed care control has resulted in a fragmented, pluralistic health care system, medical and scientific breakthroughs continue to save lives, in part the result of individual investors and corporate money – all the result of the free-market system. The multi-payer system stimulates competition and reinforces the American dream of economic reward for personal effort and achievement. To tackle health care delivery would be to tackle the entire American capitalist dream and all of its emphasis on individual well-being and limited obligation to the collective good. Thus, the only answer may be a little give and take from both sides. Unfortunately, no one has devised that compromise yet.